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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTM&T SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 J U N `� LU 10 <br /> MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.s v / T UNIT IV <br /> I <br /> —Tv n �l N I -IEA <br /> WELL PERMIT APPLICATION FLRNrsMUM!U.LS <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County\Ennvironmental Health DepartmenL <br /> well Location 35275 wCI fy W6.,,stet 1 �WGc 33 city e✓�a l l 5 Zip S38 S P Assessor's <br /> -�y <br /> Property <br /> Owner -mor (.(✓If2 rAddress 3 I ay)P1 Dr;Ve City ke, V)f 1 r�`;a Zip IG l c� <br /> D Phone# 25 —/965 <br /> C-sr ContractorkA6 fIL' b1f;/1 Address�L 72 •Ad Ict?_ .)�t� Gty Zip151T6LM ^ Phon&61 <br /> Consultant/SubCMr Vll�lA(M-SAI(Address I000 860d wg)(a S '67SCity (�AK�AN]� ��# Phone S5� <br /> GIS Coordinates:X Y Township Range Section <br /> RK TO BE PERFORMED: <br /> :RJNEW WELUBORING(CPT,GEOPROBE.HYDROPUNCH,HAND-,�UGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# TWO GCOPP-086 SoK- l�o/R/AJG S ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECCiFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3-7 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS_ i TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL FO 701 !L R>`EMIE TYPE TO BE USED❑AUGERSgMeBE PVC <br /> C <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yess (NOTE:nMAXIMUM FREE-FALL DEPTH IS 30') <br /> fNo <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS D rtlA IGC Ce w f 4± <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH -fe e f ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (d YES.list Wed effli ns in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify at 1 have preps appi n and that the work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> RegulationaVa, licabie Laws. L <A <br /> Signed Title/Company r0 fe LT �k7a f� &{7�GZ.(�l f ✓!T <br /> Print Name W I IQ✓YI ✓C joj. l Date <br /> / DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY <br /> DATEISSUED L'AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHEe" e RECV'D BY DATE PERMITISERVICE# INVOICE <br /> nSR# 60 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PER IT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />